Notice Regarding Food Allergy Accommodation
Restaurant

General Manager
We do our best to accommodate customers with food allergies to make sure they can enjoy their meals.
We will suggest dishes according to your dietary requirements.
If you agree to the following, please fill out the "Food Allergy Questionnaire" on the reverse side of this form.

1. The questionnaire does not ask about "likes and dislikes".
2. The information on the ingredients used is based on data provided by the manufacturer.
3. Because we prepare all of our dishes in the same kitchen and share cooking and cleaning equipment,
it is possible that a small amount of allergens may be introduced into the food during the cooking process.
In addition, there is a possibility that a small amount of allergens contaminate the ingredientsduring the manufacturing process.
4. Because of the reasons mentioned above, please note that the menu is not completely allergen-free.
Please note that for the safety of our customers, we will refuse to provide services to those with severe
allergic symptoms, such as those who have previously suffered from anaphylaxis, those who have been prescribed
an EpiPen, and those who are currently undergoing medical treatment for food allergies.

5. The information on the "Food Allergy Questionnaire" will be used to help ensure food safety for
those with food allergies consuming food and beverages, and will also be used to contact and provide information
to medical institutions, etc. in the event of an emergency. MAMPEI HOTEL will manage anddispose of this form responsibly, keeping in mind privacy concerns.

● If you agree to the conditions listed above and would like to request a menu that accommodates your dietary requirements,
please sign below.

YearMonthDay

Signature (person filling out the form)

レストラン使用欄 （ご予約内容等）

2024.5 改訂

Food Allergy Questionnaire① Please fill in your information
Date of your visit

YearMonthDay

Restaurant□Male□Female

GenderName

AgeName of the person
filling out this form
(Relationship to theindividual)

Person fillingout this form
Contact
phone numberYears

Gender, age, and other information is requiredin the event of an emergency.
In case of emergency, the information will beused to contact and will be communicatedto medical institutions.

② Please tick the foods you are allergic to and describe each symptom (respiratory symptoms, digestive symptoms,skin symptoms, etc.).
□ Shrimps□ Kiwi□ Crab□ Beef

□ Walnuts□ Sesame□ Wheat□ Salmon□ Buckwheat□ Mackerel□ Eggs□ Soy□ Milk□ Chicken□ Peanuts□ Bananas□ Almonds□ Pork□ Abalone□Macadamianuts□ Squid□ Peaches□ Salmon roe□ Mountainyams□ Oranges□ Apples□ Cashews□ Gelatin□ Other (Please provide as much information as possible.)

For the safety of our customers, we regret to inform you that we are unable to accommodate the following individuals.
・Those who have had anaphylactic reactions before.
・Those who have been prescribed an EpiPen.
・Those who are currently receiving medical treatment for food allergies.
・Any other person with serious symptoms.
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